August 2017

Ophthalmologist to the pro athletes

by Liz Hillman EyeWorld Staff Writer

Dr. Hersh is team ophthalmologist for the New York Jets NFL team.
Source: Peter Hersh, MD

Team ophthalmologists share what it’s like to be on the sidelines

The NBA Memphis Grizzlies were in the playoffs, and one player in particular was hot. He was hitting every shot, carrying the game for his team. Then he got poked in the eye. Now warming the bench, this player watched as the lead he’d help build got smaller.
As the team ophthalmologist, Rolando Toyos, MD, medical director, Toyos Clinic, Memphis, Tennessee, knew he could get this player back in the game within minutes—if only the player would let him.
“He had a real phobia of anyone getting near his eye, and he was ornery,” Dr. Toyos said.
As Dr. Toyos put it, opening this patient’s eye would be like prying open a crocodile’s mouth.
“I said, ‘I can get you back in that game. I can put a numbing drop and a contact lens in so that you don’t feel this thing, and I can get you back in the game, if you want to go,’” Dr. Toyos recalled.
Side-eyeing Dr. Toyos—and the scoreboard—the player, who had a corneal abrasion, agreed to the numbing drop and contact lens.
“It was the hardest contact lens I’ve ever put in,” Dr. Toyos said of the player’s reluctance.
The player was back in the fourth quarter of the game and his was the winning shot.
This is just one of hundreds of memories Dr. Toyos accumulated in his 10 years as the team ophthalmologist for the Grizzlies. Dr. Toyos has also treated professional athletes from football players to baseball players to boxers and others. He authored a book, The Life and Times of a Sports Ophthalmologist, published in 2015, detailing some of his experiences.
So how does one get to be a team ophthalmologist in the first place?
Dr. Toyos started seeing athletes with ocular injuries as a resident at Northwestern University, Chicago. He was in practice in Memphis when the Grizzlies moved into the area and asked him to be the team ophthalmologist.
For Peter Hersh, MD, team ophthalmologist for the NFL New York Jets, it was related to his long-standing interest in eye injuries, having coauthored the book Eye Trauma, and research he had done years prior with then-resident Bruce Zagelbaum, MD, Hicksville, New York, on the topic of professional athletes and sports eye injuries. Dr. Zagelbaum subsequently authored the book Sports Ophthalmology and became the team ophthalmologist for the Jets when they were located in Long Island. When the team moved to Florham Park, New Jersey, they called Dr. Hersh. Dr. Zagelbaum has remained involved in professional sports as chief ophthalmology consultant to the NFL, and he and Dr. Hersh continue to do research together looking at sports ophthalmology. Recently, they completed a study showing that professional football players in “skill” positions demonstrate faster visual reaction times.1
The types of injuries and time commitment for the ophthalmologist vary from sport to sport, Dr. Toyos said.
“The time commitment is huge when you’re talking about a sport like basketball or football,” Dr. Toyos said, noting that the team ophthalmologist for these sports is expected to be at every home game to treat the ocular injuries of both the home and visiting teams.
As far as the NFL is concerned, Dr. Hersh said the team ophthalmologists start ramping up shortly after the draft with newly signed and returning players receiving eye exams.
Dr. Toyos broke down ocular injuries sport by sport, in terms of the most common he sees:
• Basketball: Corneal abrasions, orbital fractures, optic nerve evulsion, conjunctival lacerations. “These are big guys with elbows swinging all over the place,” he said.
• Football: Poke in the eye, corneal abrasions, orbital injuries
• Baseball: Hit by a pitch, corneal abrasions, contact lens-related issues
• Boxing: Retinal detachment, traumatic cataract, other trauma-induced issues
• Hockey: Puck to the eye. In 2013, the NHL issued a mandatory visor rule for new players entering the league; those already in the league were not required to start wearing visors, although the majority do.2
Dr. Toyos said he thinks ophthalmologists can play a role in identifying players with concussions as well. A few years ago, he developed the Toyos Concussion Detection Test. The idea is to take a baseline pupillometry measurement of athletes at the start of the season. If they take a hit that could potentially cause a concussion, pupillometry is done on the sidelines again to determine if there are any changes from their baseline measurement. A few studies have also suggested that pupillometry could be used to help assess athletes with possible concussions.3,4 Dr. Hersh said that in professional football, the team internist and neurologist take the lead in concussion evaluation. Team ophthalmologists, he said, are also responsible for determining ocular conditions requiring specialized equipment such as tinted helmet visors.
Then there’s the aspect of refractive surgery. An athlete’s interest in refractive surgery seems to vary by sport, from Dr. Toyos’ perspective. For example, he’s had some basketball players who, even though they’re seeing 20/50, refuse to wear goggles or contact lenses, let alone consider a low-risk surgery that could greatly improve their eyesight. Those who are amenable to LASIK require more hand-holding.
Baseball players, on the other hand, seem far more likely to opt for LASIK, according to Dr. Toyos, who has worked with the AAA major league St. Louis Cardinals and minor league Memphis Redbirds.
“The difference between a major league baseball player and a minor league player is razor thin. If they can get an advantage doing anything, they’re going to do it,” he said.
Dr. Hersh has treated many professional basketball and football players and advises those who are candidates for refractive surgery to wait until the off-season for the procedure. He also considers the athlete’s field position in the discussion of refractive surgery.
“There is always the question with refractive surgery of what are the benefits going to be and what position do they play; depending on position, there are different tolerances of vision, whether they’re a wide receiver, who you would expect would require the best vision, or a lineman, who might require less. You want to select the candidates properly but also treat them so they are ready for the season,” Dr. Hersh said.
In the proper candidates, Dr. Hersh recommends LASIK over PRK because he finds it more accurate in his hands and easier to retreat. As for flap dislocation, he’s only seen this occur in very severe accidents.
While a team ophthalmologist might be on hand for every home game, depending on the sport, and on-call for others, Dr. Toyos said he only sees an ocular injury one out of every five games, on average. Dr. Hersh said he’ll treat an ocular injury with the Jets once or twice a season, and often a day or so after game day.
Team ophthalmologists don’t just treat the players. If there’s an injury in a fan or other staff member during a game or practice, the physician might be called in to look at that person, Dr. Toyos said.
“My advice for anyone who is close to the action is … you’ve got to be as aware as the players because you never know what’s going to come at you,” he said.
As a perk, the team and staff send many of their family members your way, but one of the drawbacks to being a team ophthalmologist, Dr. Toyos pointed out, is higher malpractice premiums.
In the end, whether you’re a team ophthalmologist or treating professional athletes as part of your everyday patient base, Dr. Hersh said you’ve got to remember “they’re regular people and regular patients.”
“The key when doing surgery is to make sure they’re routine; don’t do anything different because they’re a professional athlete. Set proper expectations. You don’t want to overpromise, and you want to set the tempo of improvement so that they have plenty of time to adapt and get used to the vision and to any minor fluctuations that might happen, as with any patient,” Dr. Hersh said. “Just like with a family member, treat them like regular patients and do your standard routine. But remember that professional athletes are smart, aggressive, at the top of their field, and they want to get things done quickly and done well. During pre-season physicals, they compete to have the best vision of anyone on the team, so even there you can see what makes them tick as pros.”

References

1. Kalberer D, et al. Peripheral awareness and visual reaction time in professional football players in the National Football League (NFL). Optometry & Visual Performance. Article accepted for publication.
2. NHL, NHLPA agree on mandatory visors. www.nhl.com/news/nhl-nhlpa-agree-on-mandatory-visors/c-672983. Accessed April 27, 2017.
3. Ventura RE, et al. The concussion toolbox: The role of vision in the assessment of concussion. Semin Neurol. 2015;35:599–606.
4. Pillai C, et al. Vision testing in the evaluation of concussion. Semin Ophthalmol. 2017;32:144–52.

Editor’s note: Drs. Toyos and Hersh have no financial interests related to their comments.